| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
506 |
154 |
$48K |
| D0140 |
Limited oral evaluation - problem focused |
1,186 |
1,012 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
550 |
496 |
$21K |
| D1110 |
Prophylaxis - adult |
485 |
458 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
137 |
58 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
368 |
358 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
526 |
490 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
65 |
30 |
$7K |
| D1120 |
Prophylaxis - child |
280 |
268 |
$7K |
| D1206 |
Topical application of fluoride varnish |
299 |
293 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
303 |
242 |
$4K |
| D0274 |
Bitewings - four radiographic images |
158 |
156 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
38 |
37 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
50 |
46 |
$808.39 |